‘Just the two of us’: single-operator interventional left atrial appendage closure—a case report

Abstract

Background

Different procedural strategies have been published targeting to facilitate transcatheter left atrial appendage closure (LAAc). We demonstrate feasibility of a procedural set-up allowing single-operator LAAc in a selected patient.

Case summary

A 87-year-old male with persistent Afib (CHA²DS²VASc, five; HASBLED, three) was referred to our hospital for LAAc. Pre-procedural planning and device sizing with three-dimensional transesophageal echocardiography (3DTEE) confirmed a non-complex anatomy of the essential anatomical structures predicting suitability for LAAc. Therefore, the procedure was performed with a simplified single-operator interventional approach. Intraprocedural TEE guidance, device preparation, and LAAc were accomplished by the interventionalist himself. For procedural guidance, the TEE probe was arranged and handled in a technique comparable to the use of intracardiac echocardiography (ICE). Procedure time (skin-to-skin) was 21 min, left atrial access time 9 min, and fluoroscopy time was 4:28 min without the use of contrast dye. The patient was discharged the following day in good medical conditions.

Discussion

To the best of our knowledge, this is the first report on successful single-operator LAAc in a selected patient. The intervention, pre-procedural screening, and intraprocedural 3D TEE were performed by one single experienced interventionalist. This simplified technique is based on a standardized pre-procedural imaging-protocol with 3D echocardiography. According to our experience, this streamlined approach is a valuable option in non-complex LAAc cases. In the growing field of structural cardiac interventions, this approach might be an interesting option for centres with limited personal and technical resources.

Learning points.

• Emphasize the importance of pre-procedural planning for transcatheter LAA closure.

• Demonstrate the usefulness of 3D echocardiography for procedural planning and guidance during this procedure.

• Propose a simplified single-operator set-up allowing for safe and efficient completion of LAAc.

Introduction

Transcatheter left atrial appendage closure (LAAc) has been evolved as an alternative treatment option for the reduction of stroke risk in patients with atrial fibrillation (Afib) and contraindications to life-long oral anticoagulant therapy (OAC).

Timeline

Day 1:	Patient presents with persistent Afib referred for interventional LAAc
Day 1:	Three-dimensional transesophageal echocardiography (3DTEE) excludes LAA
	Thrombus, confirming feasible anatomy for LAAc
Day 2:	LAAc was successfully performed under conscious sedation
Day 3:	Patient was discharged in good clinical conditions after exclusion of device embolization and pericardial effusion with echocardiography
Day 180:	Three-month follow-up with 3DTEE confirming successful LAAc

Based on two randomized studies showing non-inferiority of LAAc over vitamin K antagonists in selected patients,¹ current guidelines give a class IIb recommendation for this therapy.²

The efficacy and safety of LAAc has been confirmed in several registries with high implantation success rates,³ and LAAc is increasingly used in selected high-risk patients after OAC failure or at prohibitive bleeding risk.

Lately, several publications compared LAAc to non–vitamin K-depending OACs (NOAC) in smaller patient groups⁴ or in matched cohorts⁵ showing non-inferiority. Two larger randomized studies are now underway aiming to consolidate these findings and consequently further expand the indications for LAAc⁶ (CATALYST, NCT04226547; CHAMPION-AF, NCT04394546).

With a continuing increase in numbers of transcatheter LAAc, it is important to optimize treatment strategies and efficacy.

With this case, we demonstrate feasibility of a procedural set-up allowing for single-operator LAAc incorporating peri-procedural planning, intra-procedural imaging, and device preparation in a selected patient under conscious sedation.

Case presentation

A 87-year-old male with permanent Afib (CHA²DS²VASc, five; HASBLED, three) was referred to our hospital for transcatheter LAAc. He had a history of recurrent lower gastrointestinal bleedings under NOAC.

His current medical therapy included apixaban 2.5 mg bid, diuretics, and optimized heart failure therapy comprising beta blocker, angiotensin 1 (AT1) blocker, and spironolactone.

Recent endoscopy showed active intestinal angiodysplasia without acute treatment option, and therefore, transcatheter LAAc was planned in this selected patient at very high stroke risk and contraindications to chronic OAC therapy.

Initial screening (timeline ‘Day 1’) with 3DTEE:

1. Ruled out anatomical contraindications for LAAc such as LAA thrombus

2. Confirmed feasible anatomy of essential structures with an intended use of an Abbott Amulet device®

3. Was used for pre-procedural planning including device sizing with multiplanar reconstruction of the LAA landing zone (Figure 1 A, B, Supplementary material online, videos S1 and S2)

Figure 1.

Pre-procedural screening and measurement. AV, aortic valve; AML, anterior mitral valve leaflet; IAS, interatrial septum; LAA, left atrial appendage; PML, posterior mitral valve leaflet. (A) 3D enface view of the left atrium showing a typical anterior location of the LAA and non-complex IAS. (B) Multiplanar reconstruction and sizing of the projected landing zone according to the anatomical landmark structures.

After written informed consent, the procedure was performed on Day 2 after hospital admission under conscious sedation via a standard left femoral venous access.

Since pre-procedural planning confirmed a non-complex anatomy for transcatheter device closure, we opted for a single-operator approach with intraprocedural TEE guidance being executed by the interventionalist using the TEE probe in a technique comparable to the handling of an intracardiac echocardiography probe.

Figure 2A shows the positioning of the 3D cardiac ultrasound machine in the catheterization laboratory covered with a sterile shell to allow for intraprocedural image adjustment and measurements (Figure 2B). In this setting, the 3DTEE probe is located lateral to the right femoral venous access line; this enables intraprocedural manipulation of the probe and procedural guidance with adequate image quality (Figure 3). Images from 3DTEE and fluoroscopy are displayed on the cath lab screen in front of the interventionalist (Figure 2C).

Figure 2.

Cath lab preparation for single-operator procedure and TEE guidance. (A) Cath lab outline with the echo-machine standing left to the operator and positioning of the TEE probe lateral to the venous access site. (B and C) Photographical pictures of the intervention and echo-guiding during LAAc.

Figure 3.

Intraprocedural echo-guidance for transcatheter LAAc. AV, aortic valve; IAS, interatrial septum; LAAo, left atrial appendage occluder; PA, pulmonary artery; VCI, vena cava superior; VCI, vena cava inferior. (A) Intraprocedural visualization of the infero-posterior transseptal puncture. (B) Biplane imaging and steering of Amulet occluder placement in the LAA. (C) Multiplanar reconstruction of the occluder with adequate positioning and sealing of the appendage. (D) 3D enface view of the lobe and disc occluder after device release.

Apixaban was discontinued 24 h prior to the procedure; after venous access, 9000 units of unfractionated heparin were given, monitoring the activated clotting time aiming to achieve > 250 s at the time of transseptal puncture. For left atrial access, the VersaCross radiofrequency (RF) system (Baylis Medical), a RF-tipped pigtail wire-based TSP system was used with the RF wire serving as an exchange support wire placed in the left upper pulmonary vein once access is achieved. Infero-posterior wire tip position and tenting of the septum were confirmed on TEE before delivering RF for TSP (Figure 3A) and advancing the wire into the left atrium. Before sheath insertion, 3DTEE was used to confirm pre-procedural measurements of the landing zone and thereby device selection. Thereafter, the transseptal sheath was exchanged over the VersaCross wire for the standard double curve 12Fr delivery sheath. LAAc was completed with a 22 mm Amulet device (Abbott medical), and 3DTEE confirmed stable position of the device without residual peri-device leakage (Figure 3B–D). Procedure time (skin-to-skin) was 21 min, left atrial access time 9 min, and fluoroscopy time was 4:28 min without the use of contrast dye. The patient was discharged the following day after the procedure in good medical conditions. NOAC was resumed (apixaban 2.5 mg twice daily) until control TEE 3 months after the procedure confirmed good interventional results without device related thrombus formation (see Supplementary material online, videos S3, S4).

Discussion

Since the early start of transcatheter LAAc in 2005, different treatment strategies have been published aiming to facilitate the procedure.⁷ The common target of all suggested techniques is the reduction of periprocedural complications. The utter importance of pre-procedural planning with 3D imaging has been emphasized in the current EHRA/EAPCI expert consensus statement on LAAc.⁷ Over the last years, novel simulation software tools have been developed facilitating procedural planning by the use of 3D imaging and thereby increasing the procedures’ safety and efficacy.^8,9

More recently the group of De Baker et al. was able to demonstrate the impact of pre-procedural planning with computed tomography (CT) on acute outcome parameters (data presented at TCT 2022). In this study, a dedicated software was used to simulate the transseptal access and device placement. As compared to a standard LAAc workflow, this approach relevantly decreased fluoroscopy time by 25%, reduced the occurrence of peri-device leaks after LAAc by 40%, and decreased the risk of mis-sizing with the need of device exchange by 50%.

These data clearly promote the use of CT imaging as a valuable option for pre-procedural planning of complex structural interventions such as LAAc. On the other hand, CT-based image analysis relevantly depends on the local centres’ expertise and availability of a dedicated analysis software. Therefore, different 3D imaging techniques have been evaluated as an alternative to CT planning with comparable results.

We and other centres routinely use 3DTEE for peri-procedural imaging. The major advantage of TEE is the availability of 3D imaging during the intervention with visualization of the dynamic changes of the LAA orifice during the heart cycle. This permits final adjustments of device sizing depending on the patient´s haemodynamics, which is of relevant importance in selected cases. Spencer et al. were able to demonstrate a relevant impact of the LA pressure on the measurable LAA diameters and orifice.¹⁰ Furthermore, TEE can be used for procedural guiding and final safety check.¹¹ Similar to the cited study of De Baker et al., our group was able to show that compared to a non-standardized workflow, 3DTEE-based procedural planning and guidance reduces procedural time by 75% and fluoroscopy time by 55% and completely mitigates the use of contrast dye during the intervention.¹²

Up to date, no definite consensus has been reached on the optimum imaging protocol for LAAc, and future studies are needed to define the so-called gold standard of interventional imaging in different clinical scenarios. According to the local experience and availability, either CT or 3DTEE can successfully be used for procedural planning with comparable results.¹³

To the best of our knowledge, this is the first report on successful single-operator LAAc in which the intervention, pre-procedural screening, and intraprocedural 3D TEE were performed by one experienced cardiologist. This simplified approach can be useful in LAAc cases of low or intermediate complexity. Moreover, it seems highly efficient without prolonging procedure or device time. An important aspect of this single-operator approach is the complete synchronization of the device handling with echo-imaging throughout the procedure. Thereby, this case highlights the usefulness of a profound understanding of cardiac imaging by implanting interventionalists. In the growing field of complex structural cardiac interventions, this approach might be an interesting option for centres with limited personal and technical resources.

Lead author biography

Prof. Christoph Hammerstingl is an interventional cardiologist and imager. He started his career at the University of Bonn where he was part of the structural heart team focused on interventional imaging. Since 2020, he is the heart of the Department of Cardiology at the Eduardus-Krankenhaus in Cologne

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports.

 

Consent: The authors confirm that written consent for submission and publication of this case report has been obtained from the patient in line with the COPE guidance, including the use of images and associated text. For supplemental videos, please see the online version of this article.

 

Funding: None declared.